Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future

7/29/2019 Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future

1/26

StatementofKennethE.Thorpe,PhD

SenateSpecialCommitteeonAging

HearingOn

StrengtheningMedicareforTodayandtheFuture

Wednesday,February27,2013,3:00pm.

Dirksen106


2/26


SenateSelectCommitteeonAging,February27,2013

2

Goodmorning,Senators.Thankyouforinvitingmeheretodaytodiscusstheurgentneed

toreformhealthcaredeliveryintheUnitedStatesandthepivotalrolethatprimarycare

providersmustplayinachangedsystem.IamKenThorpe,chairmanofthedepartmentof

healthpolicyandmanagementatEmoryUniversity.IalsoleadthePartnershiptoFight

ChronicDisease,anationalcoalitionofpatients,providers,communityorganizations,

businessandlaborgroups,andhealthpolicyexpertsthatisworkingwithstate

partnershipstopreventchronicillnessandreformhowwedelivercaretopatients.In

addition,IsitontheboardofthePartnershipfortheFutureofMedicare.

Craftingeffectivesolutionstofurtherreductionsinthegrowthinentitlementprograms

requiresaclearunderstandingofwherethedollarsarespent,andthefactorsdrivingthe

growthinspending.Todate,simplycuttingpaymentstoprovidersandMedicare

Advantageplanswillachievebudgetsavings,buttheydonotreducecostsandovertime

mayultimatelyreduceaccesstocare.VirtuallyallthespendingintheMedicareprogramis

associatedwithchronicallyillpatients.Highandrisingprevalenceofchronicdiseasessuch

asdiabetesareakeycontributortothegrowthinMedicarespending.Yetdespitethe

centralrolethatchronicdiseaseplaysinMedicare,theprogramdoesnotcoverlifestyle-

relatedpreventivebenefitsandcurrentlydoesnotprovidecomprehensivecare

coordinationformostpatients.AkeydirectionforreformingMedicareneedstofocuson

reducingtheriseinpreventablechronichealthcareconditions,andintroducingevidence-

basedelementsofcarecoordinationintotraditionalMedicare.


3/26



3

Fortunately,wehaveasubstantialbodyofpublishedresearchhighlightingtheimpactthat

keyelementsofcarecoordinationandpreventionhaveonreducingspendingand

improvingquality.ComponentsofthesedataarederivedfromtheexperienceofMedicare

Advantageplans,animportantpartoftheMedicareprogram,aswellasothercare

coordinationinitiativesintheprivatesector.1Identifyingthebestpracticetechniquesand

adoptingthemintotraditionalMedicareshouldbeakeyfocusofentitlementreform.These

keypreventionandcarecoordinationinitiativesthathaveprovenclinicallyeffectiveand

costreducingincludetransitionalcare,comprehensivemedicationmanagement,health

coaching,andteambased,wholepersonfocused,care.Inadditiontocarecoordination,

makingevidence-basedprogramslikethediabetespreventionprogram,aprogramwith

establishedresultsthatreducetheincidenceofdiabetesandrelatedchronicconditions

amongadults(andseniorsinparticular)shouldbeaddedtotheMedicareprogram.

IntroductionofthesepreventiveandcarecoordinationinitiativesintotraditionalMedicare

willslowthegrowthinspendingandimprovethequalityofcareprovided.

VirtuallyallthespendingintheMedicareprogramisassociatedwithpatientswithmultiple

largelyunmanagedchronicconditions.Recentresearchexaminingthegrowthinspending

intheMedicareprogramfoundthat:

1Thorpe,KE,TheMedicareAdvantageExperience:LessonsforReformtoOriginalMedicare.manuscript.,

December2012.EmoryUniversity.


4/26



4

About95percentofspendingintheprogramisassociatedwithpatientswithoneormorechronichealthcareconditions;2

Over53percentofMedicarepatientsweretreatedforfiveormorechronicconditionsduringtheyear.Thesepatientsaccountedfornearly78oftotalMedicare

expenditures.3(SeeAppendix1).

MostoftheriseinMedicarespendingistracedtorisingratesoftreateddiseaseprevalenceandincreasedintensityoftreatment;

Nearly85percentofthegrowthinMedicarespendingsincethelate1980sisassociatedwithpatientstreatedforfiveormoremedicalconditions;(tabulationsfrom

Appendix1).

Risingratesofobesityamongseniorsaccountsforapproximately10percentoftheincreaseinspending;4

TwentypercentofhospitalizedMedicarepatientsarereadmittedtothehospitalwithina30daywindow.Thesereadmissionsarepotentiallypreventableandcould

accountformorethan$500billioninspendingoverthenextdecade.5

One-fourthofalladultswenttoanemergencyroomforaconditionthatcouldhavebeentreatedinamorecost-effectivenon-emergentsetting.

Collectively,thesedatahighlighttheneedforpolicyproposalsthataredesignedtoreduce

theriseintheincidenceofpreventablechronicdisease,moreeffectivelymanageand

engagechronicallyillpatients,andreduceclinicallyunnecessaryuseofhealthcare

services.

Theremainingpartofmytestimonywillfocusonthreeissues.First,whatchangeshasCMS

madetostartintroducingelementsofcarecoordinationintothetraditionalMedicare

2http://www.fightchronicdisease.org/sites/fightchronicdisease.org/files/docs/Thorpe%20-%20Care%20Coord%20Savings%20-%20Final-1.pdf

3http://content.healthaffairs.org/content/25/5/w378.full.pdf+html

3http://content.healthaffairs.org/content/28/5/w822.full

5http://nyshealthfoundation.org/uploads/general/conversation-with-kenneth-thorpe-diabetes-prevention-program.pdf


5/26



5

program.Second,howcanweacceleratetheadoptionofteambasedcarecoordinationin

traditionalMedicare?Alongtheselines,whatdothepublishedrandomizedtrialsplusthe

experiencewiththeprivatesectortellusabouttheelementsofcarecoordinationthat

improvequalityandhealthoutcomesandreduceMedicarespending?Third,howcanwe

replicateandscalethesebestpracticesintotraditionalMedicareoverthenextcoupleof

years.TheMedicareprogramneedstopivotquicklyfromapilotmentalitytothe

implementationofbestpracticesprogramwide.

ProgresstoDate

Medicarecurrentlycoversseveralpreventiveservices,includingawiderangeofclinical

preventiveservices.Inaddition,theprogramalsocoversaninitialpreventionphysical

exam,andanannualwellnessvisitthatcouldincludeahealthriskappraisalanda

personalizedpreventioncareplan.Howeverwhiletheprogramiswellsuitedtoidentifying

at-riskseniors,itdoesnotcoverservicesthatwouldallowseniorstoaddresstheserisk

factors.Forinstance,Medicaredoesnotcoverintensivelifestyleinterventionslikethe

diabetespreventionprogramorFDAapprovedobesitymedicationsdesignedtoassist

obeseseniorsatriskforarangeofchronicconditions.Inshort,Medicarewillhighlightthe

needforanactionplanandidentifyat-riskseniors,butprovidesnocoveragethatwould

actuallyassistseniorsinhelpingmeetlifestylegoalspersonalizedcareplan.Moreover,

Medicarehastraditionallynotcoveredanycarecoordinationthatwouldengageseniors

withmultiplechronicconditionstoremainhealthyandoutofthehospital,ERorclinic.


6/26



6

TheCenterforMedicareandMedicaidServices(CMS)hasstartedtointroduceelementsof

carecoordination,thoughinawaythatmayinhibittheabilitytoallowbestpracticeteam

basedapproachesflourishintheprogram.Aspartofits2013MedicarePhysicianFee

Schedule,theCentersforMedicareandMedicaidServices(CMS)startedtointroduce

elementsofcarecoordination.The2013feeschedulenowincludesnewcodes(HCPCSG-

code)thatwillallowphysicianstoreceiveabundledpayment(onlyabout$55onaverage)

toprovidetransitionalcareservicestopatientsdischargedfromahospital,nursinghome

orrehabilitationfacility.6Whilethisiscertainlyanimportantfirststarttowardintroducing

carecoordinationintotraditionalMedicare,transitionalcaremanagementislikelybest

providedbytrainednursepractitioner,ornursecoachesusingevidence-basedmodelsthat

Iwilldiscussfurtherbelow.Moreover,usingmultiplebillingcodesmaymakethetransition

toteambasedcare(nurses,nursepractitioners,mentalhealthworkers,pharmacists,social

workersandothers)thatprovideabroaderrangeofcarecoordinationfunctionsdifficultto

achieve.

OptionsforIncludingEvidence-BasedPreventionandCareCoordinationinto

TraditionalMedicare

Designingevidenced-basedpreventionandcarecoordinationapproachesfortraditional

Medicarerepresentsamajorpolicychallenge.Oneplacetostartistoexaminethe

6BindmanA,BlumJ,KronigR.MedicaresTransitionalCarePayment-ASteptowardtheMedicalHome.NEJM

2013;368(8):692-694.


7/26



7

experiencewithMedicareAdvantageandseewhatevidenceexistsaboutbestpractice

approachesforreducingcosts,improvingqualityandensuringpatientsatisfactionthat

couldbemadeavailabletothosebeneficiarieswhoaccountforthelargestsegmentofthe

MedicarepopulationthoseintraditionalMedicare.InadditiontoMedicareAdvantage,

thereisaconsiderablebodyofpublishedresearchthathasevaluatedcoreelementsofcare

coordination.RecentpublicationshavedemonstratedthatinnovativeMedicareAdvantage

programscanreducetotalMedicarespendingandprovidethesameorbetterqualityof

carethantraditionalMedicarebyupto15to20percent.7Howdotheseplansachieve

thesesavings?Theyusepredictivemodeling,targetinterventionstowardhigh-riskseniors,

transitionalcare,highriskcasemanagement,medicationtherapy,managementand

adherence,healthcoaching,andteam-basedcare,amongothers.8Thedataalsohighlight

theimportanceofcloseinteractionandintegrationofcaremanagersandphysician

practices.HealthteamsinVermontandNorthCarolinaaregoodexamplesofthisclose

interactionbetweencarecoordinatorsandproviderspractices.Largerandomizedtrials

havealsoevaluatedtheimpactofcomprehensivelifestylemodificationinterventionssuch

7MilsteinA,GilbertsonE.AmericanMedicalHomeRuns,Fourreallifeexamplesofprimarycarepracticesthat

showabetterwaytosubstantialsavings.HealthAff(Millwood)2009;28(3):1317-1326,andLandonBEetal.

AnalysisofMedicareAdvantageHMOsComparedwithTraditionalMedicareShowsLowerUseofManyServices

During2003-2009,HealthAff(Millwood).2012;31(12):2609-2617andCohenR,etal.MedicareAdvantageSpecial

NeedsPlansBoostedPrimaryCare,ReducedHospitalUseamongDiabeticPatients.HealthAff(Millwood)2012;

31(1):100-119.

8http://content.healthaffairs.org/content/31/6/1156.full


8/26



8

astheDiabetesPreventionProgramandtheStanfordChronicDiseaseManagement

Program.9

Ihaveoutlinedseveralstepsthatwouldbeneededtointegrateevidence-basedprevention

andcarecoordinationintothetraditionalMedicareprogram.Carecoordinationcouldbe

offeredasanopt-outserviceforallpatientsinthetraditionalMedicareprogram.The

serviceswouldbeofferedbyhealthplans,homehealthagencies,managedcarevendors,or

othersthatcouldprovidetherangeofservicesoutlinedbelow.Carecoordinatorswouldbe

selectedthroughcompetitivebidding.Anotheroptionwouldbetogiveseniorsofchoiceof

stayingintraditionalMedicare(withnopreventionandcarecoordination)orselectinga

newversionoftraditionalMedicare,MedicarePlusthatwouldincludethecare

coordinationservices.

TransformingtraditionalMedicarewouldrequirethefollowingsteps:

1. TransitionAwayfromFee-for-Service

AkeytointroducingcarecoordinationintotraditionalMedicareistotransitionawayfrom

fee-for-servicepaymentsandasastartreplaceitwithmorebundledpayments.The

incentivestoincreasethevolumeofservicesinfee-for-serviceruncompletelycounterto

theincentivestoprovideclinicallyeffectivecarecoordination.Asfee-for-serviceisphased

outovertime,itwouldbereplacedbybundledpaymentsfor(most)hospitaladmissions

9http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61457-4/fulltextand

http://patienteducation.stanford.edu/programs/cdsmp.html


9/26



9

thatincludeallcoveredpost-acutecareservices30daysafterdischarge.Thereisbroad

agreementthatMedicaresfee-for-service(FFS)paymentmodelisoutdated,drivesup

additionalvolumeofservicesandmustbereplacedtoimprovehealthcaredelivery.Our

entirehealthcaresystemisbuiltaroundFFSandupdatingourcurrenthealthcaredelivery

structurewillsetthestageforaninnovative,high-qualityhealthcaresystem.However,

transitioningawayfromFFSwillnotbeeasyandwillnothappenovernight;reformingthe

Medicaresystemsothatitpaysforqualitywillrequiresignificantdatacollectionand

monitoring,updatestoregulations,andtestingandscalingofnewandinnovativepayment

modelsandincentives.AdvancingtheseobjectivesandfacilitatingagradualshiftfromFFS

medicinewilltaketimeandwillthereforelikelyoccurinstagesandleadtoanumberof

newpaymentmodelreforms.Asaninterimstep,broaderuseofbundledpaymentswith

qualitycontrolsfocusedonhealthimprovementwouldprovideausefultransitionalstep.

Physicianpracticesthatworkwithhealthteamstoprovidecarecoordinationservices

(outlinedbelow)shouldreceiveabundledpaymentaspartoftheircollaborationwiththe

healthteams.

2. AddInterventionsthatAvertDiseaseAmongOverweightandObeseAdultsintotheMedicareprogram


10/26



10

Perhapsthebest-knownlifestylemodificationprogramistheDiabetesPreventionProgram

(DPP).RandomizedtrialsofotherprogramssuchastheStanfordChronicDisease

ManagementProgramproduceresultssimilartotheDPP.TheoriginalDPPprotocolwas

deliveredtooverweight,pre-diabeticadultsonaone-on-onebasis.Thelargescale

randomizedtrialoftheDPPfoundthatlifestyleinterventionreducedtheprevalenceof

diabetesby58percentrelativetoplacebo.Thereductionindiabetesprevalence(aswellas

hypertension)wastracedtoa7percentreductioninweightamongparticipants.The

largestreductionsinweightanddiabetesprevalenceoccurredamongparticipantsaged60

andolder.Those60andolderlostanaverageof8.2percentoftheirstartingweightafter

12monthscomparedto7.5percentforthoseaged45to59and6.6percentforadults

underage45.10Asaresult,theprevalenceofdiabeteswas71percentlowerthanplacebo

forthose60andoldercomparedtotheoverallaverageof58percent.11.Inotherwords,

amongevery100overweightorobeseadultswhocompletedtheintensivelifestyle

intervention19outofanexpected33failedtodevelopType2diabetes.Forthose19

individuals,thesocialandfinancialcostsofanewdiabetesdiagnosisforsuchnecessities

asadditionaltests,diabeteseducation,glucosemeters,teststrips,andmoreintensive

managementofothercardiovascularriskfactorswereavoided.Moreover,forevery100

adults,8avoidedtheneedforbloodpressureandcholesterolmedications.

MakingtheDPPacoveredbenefitundertraditionalMedicarewouldsavetheprogram

moneyandimprovehealthoutcomes.Thisproposalwouldbuildonthefoundationofthe

10http://www.nejm.org/doi/pdf/10.1056/NEJMoa012512

11http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/


11/26



11

YMCAcommunitybaseddiabetespreventionprogramsinplace,andcurrentlyunder

expansion.Thisproposalwouldallowpre-diabeticorotheratriskseniors(basedonthe

resultsoftheirwellnessplanandaspartofthepersonalizedpreventionplandevelopedby

theirphysician)overweightandobeseseniorswouldbeeligibletoenrollintheprogram.

Dependingonparticipatingrates,justenrollingonecohortofoverweight,pre-diabetic

seniorsintotheprogramwouldgenerateanetsavingstoMedicareofabout$2to$4Billion

over10yearsandmorethan$6to15Billionduringthelifetimesofthoseparticipatingin

theprogram.12Similarconsiderationshouldbegiventoincludingtherecentlyapproved

FDAweightlossdrugsasacoveredMedicarebenefitinlightoftheimpacttheyhaveon

weightloss(around10to15percentreductions).

3. ContractwithhealthteamstoprovidecarecoordinationforchronicallyillMedicarepatients.

OverhalfoftheMedicarepopulationisundertreatmentfor5ormorechronichealthcare

conditions.Theseincludementalhealth,behavioralhealth,andcardiovascularevents

amongothers(diabetes).Effectiveprovisionofteam-basedprimarycarehasbeenshown

12ThorpeKEandYangZ.Enrollingpeoplewithprediabetesages60-64inaprovenweightlossprogramcouldsave

Medicare$7Billionormore.HealthAff(Millwood)2011;30(9):1673-1679


12/26



12

toimprovethequalityofcareatlowercosts13.Thereforeeffectivecomprehensiveclinical

engagementrequiresmulti-specialtyteamsofproviderswiththeflexibilitytousetheir

resourcesbasedonthepatientsneeds.Thereisagrowingbodyofevidencethathas

identifiedthekeyfunctionsperformedbyhealthplansandsuccessfulcomprehensive

team-basedcarecoordinationmodelsinmanagingchronicallyillpatients.Health(or

chroniccare)teamsincludeaclinicalleader(nurse,nursepractitioner)coordinatingthe

careplanprovidedbythephysician,nurses,nursepractitioners,pharmacists,social

workers,behavioralhealthspecialistsandhealthcoaches.Theseteamswouldprovidethe

followingevidencebasedfunctionswhencoordinatingcarel.14Coordinationofcareforall

coveredMedicareservicesutilizingateam-basedapproach

Approachesthatprovideawholepersonfocusonpreventingdiseaseandmanagingacute,andmentalhealthservices

Medicaladvicefromacarecoordinatoravailable24/7 Assessmentofpatientriskperhapsanddevelopmentofanindividualizedcare

plan

ComprehensiveMedicationManagement Transitionalcareandhealthcoaching Regularcontactwithenrollee Closeintegrationofthecarecoordinatornurseandprimarycare(and

specialist)physicians

13MedicarePaymentAdvisoryCommission.2008.ReporttotheCongress:Reformingthedeliverysystem.

WashingtonDC:MedPAC.

14


13/26



13

Evidence-basedhealthcoachingtotrainpatientself-managementskillsandfacilitatebehaviorchange.

Theseactivitiesprovidethefoundationforcostsavingsmovingforwardandimproved

healthoutcomeswhencoordinatingcareforchronicallyillpatients.Eachofthemajor

functionsoutlinedabove(transitionalcare,medicationadherence,healthcoaching)have

severalpublishedrandomizedtrialsshowingtheyindividuallyresultinimprovedhealth

outcomesatlowerlevelsofhealthcarespending.Collectivelytheyserveasapowerful,

team-basedapproachtogeneratesubstantialprovensavingsandimprovedqualityofcare.

Abriefsummaryofsomeoftherandomizedtrialshighlightingtheclinicaleffectivenessand

costsavingsassociatedwiththesecarecoordinationfunctionsispresentedbelow.

TransitionalCare.

TwoofthebestknownmodelsoftransitionalcarehavebeendevelopedbyEricColemanat

theUniversityofColoradoandMaryNaylorattheUniversityofPennsylvania.Theteamat

Penndefinestransitionalcareasprovidingcomprehensivein-hospitalplanningandhome

follow-upforchronicallyillhigh-riskolderadultshospitalizedforcommonmedicaland

surgicalconditions.TheheartofthemodelistheTransitionalCareNurse(TCN),who

followspatientsfromthehospitalintotheirhomesandprovidesservicesdesignedto

streamlineplansofcare,interruptpatternsoffrequentacutehospitalandemergency

departmentuse,andpreventhealthstatusdecline.WhileTCNisnurse-led,itisa

multidisciplinarymodelthatincludesphysicians,nurses,socialworkers,discharge


14/26



14

planners,pharmacists,familycaregivers,andothermembersofthehealthcareteaminthe

implementationoftestedprotocolswithauniquefocusonincreasingpatients'andfamily

caregivers'abilitytomanagetheircare.ForthemillionsofAmericanswhosufferfrom

multiplechronicconditionsandcomplextherapeuticregimens,TCMemphasizes

coordinationandcontinuityofcare,preventionandavoidanceofcomplications,andclose

clinicaltreatmentandmanagement-allaccomplishedwiththeactiveengagementof

patientsandtheirfamilyandinformalcaregiversandincollaborationwiththepatient's

physicians.Moreinformationisavailableathttp://www.transitionalcare.info/.

Asecondmodel,developedbyEricColemanusestransitioncoachestotrainpatientsand

familycaregivershowtomanagetheircare.Transitioncoachesaregenerallynot

physicians,butarenursepractitioners,nurses,orcommunityhealthworkers.Tosmooth

transitionsfromhospitaltohome,theCareTransitionsIntervention(CTI)usescoaching

andhomevisitsbytrainedcarecoordinators.Thecoachmakesonehomevisitandseveral

phonecallstothepatientovera30daywindow.Moreinformationonthisprogramis

availableatwww.caretransitions.org.

Accordingtorandomizedtrials,bothprogramsreducedramaticallyhospitalreadmission

rates.AmongMedicarepatients,theTCIprogramreduced30dayreadmissionsby30

percent.andat90dayshospitalcostsby25percent.15RandomizedtrialsoftheTCN

15ColemanEA,etal.TheCareTransitionsIntervention,ResultsofaRandomizedControlledTrial.ArchInternMed.

2006;166:1822-1828


15/26



15

modelhavedemonstratedreductionsinreadmissionsof56percentwithsimilar

reductionsintotalMedicarespendingafteroneyear.16

ComprehensiveMedicationManagement

Poormedicationmanagementaddssubstantiallytotheoverallcostofhealthcare,bysome

estimatesaddingover$200billionperyearinadditionalhospitalandotherspending.17

Comprehensivemedicationmanagementprovidedaspartofanintegratedhealthteamhas

showntosaving$1.29inhealthcarespendingforevery$1spenttoadministerthe

program.18Moreover,arecentlysummaryofthepublishedresearchliteraturebythe

CongressionalBudgetOffice(CBO)foundthatadherenceandpersistencyintaking

medicationsalsoreducesspending.SpecificallytheCBOfoundthatevery1percent

increaseinprescriptionsfilledwouldreduceMedicarespendingby0.25percent.19Under

thePartDprogram,drugplansmustoffermedicationtherapymanagementprogram

(MTM).However,thecriteriafortargetingMedicarebeneficiariesenrolledinPartDplans

16MDNaylor,DABrooten,RLCampbell,GMaislin,KMMcCauley,J.S.Schwartz.Transitionalcareofolderadults

hospitalizedwithheartfailure:arandomized,controlledtrial.JournaloftheAmericanGeriatricsSociety.May

2004;52:675-84.Seealso:MDNaylor,DBrooten,RJones,etal.Comprehensivedischargeplanningforthe

hospitalizedelderly.AnnalsofInternalMedicine1994;120(June):999-1006. MD Naylor, DA Brooten, R Campbell,

et al. Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American

Medical Association 1999; 281:613-20. MD Naylor. Transitional care of older adults. Annual Review of Nursing

Research. 2003; 20:127-47.

17JohnsonJA,BootmanJL.Drug-relatedmorbidityandmortality:acostof-illnessmodel.ArchInternMed.1995;155:1949195618D. Ramalho de Oliveira, A. Brummel, and D. Miller, Medication Therapy Management: 10 Years of Experience

in a Large Integrated Health Care System,Journal of Managed Care Pharmacy 16, no. 3 (April 2010): 18595.

19CongressionalBudgetOffice,OffsettingEffectsofPrescriptionDrugUseonMedicaresSpendingforMedical

Services.CBOWashingtonDCNovember2012.


16/26



16

arethosewithmultiplechronicconditions(maximumof3)andwithexpectedannualdrug

spendingfor2013of$3,144.20However,thecurrentMTMprogramwouldnotinclude

patientswithhighPartAandBmedicalcoststhatmaynotbeappropriatelytaking

medications(non-adherent,etc)andwouldnothitthe$3,144spendingthreshold.Indeed,

poormedicationmanagementhasbeenlinkedto32percentofallhospitalizationsanda

keycauseofpreventableadverseeventsamongMedicarepatients.21Recentstudieshave

demonstratedthatteambasedmedicationmanagementcare,aspartofanoverallcare

coordinationclinicalstrategy,reducedthegrowthinspendingby11percent.22

AspartofthenewcarecoordinationservicesintraditionalMedicare,thecurrentMTM

programshouldbebroadenedandintegratedintotheoverallsetofcarecoordination

servicesprovided.Apharmacistworkingaspartofthecarecoordinationteamwouldwork

withpatientsthathavehighprioryeartotalMedicarespending(notjustthosewithhigh

PartDspending)toresolvedrugtherapyissues(drugeffectiveness,dosage,compliance

andadherence).Thisbroaderapproachwould,aspartoftheoverallcarecoordination

team,linkmedicationmanagementandresolvingdrugtherapyproblemstoclinical

improvementsinseniors.Substantialworkhasalreadybeencompletedonthedesignof

20http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Memo-

Contract-Year-2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf

21atwww.oig.hhs.gov/oei/reports/oei-06-09-00090pdf,andSmithM,etal.,Whypharmacistsbelonginthe

medicalhome.HealthAff(Millwood)2010;29(5):906-913

22IsettsB.etal.Managingdrug-relatedmorbidityandmortalityinthepatientcenteredmedicalhome.MedCare

2012;50:994-1001


17/26



17

suchabenefitfromthePatient-CenteredPrimaryCareCollaborativeandtheAgencyfor

HealthcareResearchandQualityInnovationExchangeQualityToolkit.

HealthCoachingandPatientLiteracy

Coachingprovidespatientswithoneormorechronicconditionstounderstandtheircare

plan,participateinshareddecisionmakingwiththeirhealthcareproviders,andmore

effectivelynavigatethehealthcaresystem.Understandthecareplan,andworkingto

consistentlyexecuteitisanimportantapproachforreducingunnecessaryutilizationof

healthcareservices.TheHealthEffectivecoachingempowersindividualswithawide

rangeofconditionsincludingbutnotlimitedtochronicconditions,toparticipatein

medicaltreatmentdecisionswiththeirdoctors.Coachingwouldbeanotherkeycomponent

ofcarecoordinationservicesprovidedintraditionalMedicare.Alargerandomizedtrial

conductedbyHealthDialogandpublishedintheNewEnglandJournalofMedicineutilized

telephonichealthcoachingtoworkwithalargepopulation(morethan174,0007,000of

whomwereMedicarepatients)ofpatients.23Thisrecentrandomizedtrialshowedthat

totalhealthcarespendingwas3.6percentlowerinthetreatmentgroup(yieldingabouta3

percentnetsavingsafteraccountingforthecostoftheintervention).Thissingle

componentofcarecoordinationalonereducedhospitalizationsinthetrialby10percent

andtotalspendingbymorethan3percent.

23WennbergDEetal.Arandomizedtrialofatelephoniccaremanagementstrategy.,NEJM2010;313(13):1245-

1255.


18/26



18

Conclusion

Aconsiderablebodyofpublishedresearch,manyfromrandomizedcontrolledtrials,has

highlightedtheclinicalcarecoordinationfunctionsthatimprovepatientqualityandreduce

costsintheMedicareprogram.Overtime,entitlementreformwillhavetofindquality

enhancingapproachesthatalsoreducecosts.Addingintensivelifestyleprogramslikethe

DPPwouldconservativelyreduceMedicarespendingby$4billionoverthenexttenyears,

andover$15billionoverthelifetimeofoverweightprediabeticMedicarepatients.Rising

ratesofpreventablechronicillnessisamajordriverofrisingspendingintheprogram,and

addingeffectiveprogramsliketheDPPwouldaddresstheselong-termtrends.

About95percentoftotalMedicarespendingisassociatedwithchronicallyillpatients.Yet,

traditionalMedicaredoeslittletodaytoengagethesepatientstokeepthemhealthyandout

ofthehospital,emergencyroomsandclinics.Theteambasedapproachtocare

coordinationoutlinedabovecouldbescaledandreplicatedquickly(within2years)

throughouttheMedicareprogram.Thiswouldproviderapidimprovementsinthequality

ofcareprovidedtopatientswithsubstantialreductionsinspending.Basedonsuccessful

programslikeCaremore,XLHealth,andgrouppracticesliketheMarshfieldClinicand

Geisinger,overthenexttenyearsMedicarecouldeasilysavecloseto$300billionoverthe

nextdecade.Thesechangestotheprogramreallywouldconstitutehealthreforms,

reformsthatreducetheincidenceofchronicdiseaseandprovidemoreeffective

managementofpatientswithmultiplechronicconditions.


19/26



19

Thankyouagainfortheopportunitytodiscussthesevitalreforms.Imhappytotakeyour

questions.


20/26



20

References

1. GovernmentAccountabilityOffice,MedicarePhysicianPayment:CareCoordinationProgramsUsedinDemonstrationShowPromise,butWiderUseofPayment

ApproachMayBeLimited(GAO0865),Washington,DC:GAO,2008.

http://www.gao.gov/new.items/d0865.pdf(accessedOctober28,2008).

2. A.LiebhaberandJ.M.Grossman,PhysiciansMovingtoMid-Sized,Single-SpecialtyPractices,JournalofGeneralInternalMedicine20,no.10(2005):953957

3. P.R.Orszag,Director,CongressionalBudgetOffice,TheMedicareAdvantageProgram:EnrollmentTrendsandBudgetaryEffects,Testimonybeforethe

CommitteeonFinance,UnitedStatesSenate,April11,2007.CentersforMedicare

andMedicaidServices(CMS),NationalHealthExpenditures2007Highlights,

http://www.cms.hhs.gov/NationalHealthExpendData/downloads/highlights.pdf

(accessedApril7,2009).

4. B.Starfield,L.Shi,andJ.Macinko,ContributionofPrimaryCaretoHealthSystemsandHealth,MilbankQuarterly83,no.3(2005):457502.

MedicarePaymentAdvisoryCommission(MedPAC),ReporttotheCongress:

PromotingGreaterEfficiencyinMedicare(Washington,DC:MedPAC,2007).


21/26



21

MedicarePaymentAdvisoryCommission(MedPAC),StatementofMarkE.Miller,

ExecutiveDirector(September16,2008),

http://www.medpac.gov/documents/20080916_Senpercent20Fin_testimony

percent20final.pdf(accessedApril1,2009).

5. CentersforDiseaseControlandPrevention(CDC),ChronicDiseaseOverview,2005,http://www.cdc.gov/nccdphp/overview.htm(accessedApril1,2009).

6. 6G.F.Riley,LongTermTrendsInTheConcentrationOfMedicareSpending,HealthAffairs,May/June26,no.3(2007):808816.

7. K.E.ThorpeandD.H.Howard,TheRiseinSpendingAmongMedicareBeneficiaries:TheRoleofChronicDiseasePrevalenceandChangesinTreatmentIntensity,Health

AffairsWebExclusive,2006:w378w388.

8. P.R.Orszag,April11,2007.CongressionalBudgetOffice(CBO),High-CostMedicareBeneficiaries(Washington,D.C.:CBO,May2005),

http://www.cbo.gov/ftpdocs/63xx/doc6332/0503MediSpending.pdf(accessed

April7,2009).InstituteofMedicine,RewardingProviderPerformance:Aligning

IncentivesinMedicare(Washington,DC:NationalAcademiesPress,2006).

E.Wagner,C.Davis,J.Schaefer,M.VonKorff,andB.Austin,ASurveyofLeading

ChronicDiseaseManagementPrograms:AreTheyConsistentwiththeLiterature?,

ManagedCareQuarterly,1999Vol.7,No.3,pp.5666.


22/26



22

J.Chodosh,S.C.Morton,W.Mojica,M.Maglione,M.J.Suttorp,L.Hilton,S.Rhodes

andP.Shekelle,Meta-Analysis:ChronicDiseaseSelf-ManagementProgramsfor

OlderAdults,AnnalsofInternalMedicine143,no.6(2005):427438.

T.Bodenheimer,E.H.Wagner,K.Grumbach,ImprovingPrimaryCareforPatients

withChronicIllness,JournaloftheAmericanMedicalAssociation288,no.19

(2002):17751779

T.Bodenheimer,E.H.Wagner,K.Grumbach,ImprovingPrimaryCareforPatients

withChronicIllness:TheChronicCareModel,Part2,JournaloftheAmerican

MedicalAssociation288,no.19(2002):19091914.

T.Bodenheimer,K.Lorig,H.Holman,K.Grumbach,PatientSelf-Managementof

ChronicDiseaseinPrimaryCare,JournaloftheAmericanMedicalAssociation288,

no.19(2002):24692475.

S.M.Foote,Population-BasedDiseaseManagementUnderFee-For-Service

Medicare,HealthAffairsWebExclusive2003:W3342356.

CentersforDiseaseControlandPrevention,ChronicDiseaseOverview(2008),


23/26



23

http://www.cdc.gov/nccdphp/overview.htm(accessedFebruary12,2008).

D.Peikes,A.Chen,J.Schore,andR.Brown,EffectsofCareCoordinationon

Hospitalization,QualityofCare,andHealthCareExpendituresAmongMedicare

Beneficiaries:15RandomizedTrials,JAMA301,no.6(2009):603618.

9. 9D.Peikes,A.Chen,J.Schore,andR.Brown,2009.

B.W.Jacketal.,AReengineeredHospitalDischargeProgramtoDecrease

Re-hospitalization,AnnalsofInternalMedicine150,no.3(2009):178187.

E.A.Colemanetal.,PreparingPatientsandCaregiverstoParticipateinCare

DeliveredAcrossSettings:TheCareTransitionsIntervention,Journalofthe

AmericanGeriatricsSociety52,no.11(2004):18171825.

M.D.Nayloretal.,ComprehensiveDischargePlanningandHomeFollow-upof

HospitalizedElders:ARandomizedClinicalTrial,JournaloftheAmericanMedical

Association281,no.7(1999):613620.10B.Starfield,L.Shi,andJ.Macinko,

ContributionofPrimaryCaretoHealthSystemsandHealth,MilbankQuarterly83,

no.3(2005):457502.


24/26



24

MedicarePaymentAdvisoryCommission(MedPAC),ReporttotheCongress:

PromotingGreaterEfficiencyinMedicare(Washington,DC:MedPAC,2007).

MedicarePaymentAdvisoryCommission(MedPAC),StatementofMarkE.Miller,

ExecutiveDirector(September16,2008),

http://www.medpac.gov/documents/20080916_Senpercent20Fin_testimony

percent20final.pdf(accessedApril1,2009).


25/26



25

Table1.DistributionofHealthCareSpendingAmongMedicareBeneficiaries,ByNumberofTreated

MedicalConditions,1987,1997,2002,2009

MedicareBeneficiaries **2009dollars**

1987

NumberofConditions

Numberof

BeneficiariesAffected

(millions)

Percentof


AmountofHealth

Spending

($millions)

PercentofTotal

HealthSpending

0 2.8 9.5 653.7 0.4%

1 4.1 14.1 13,389.9 7.4%

2 4.6 16.1 18,284.6 10.1%

3 4.6 15.8 26,326.6 14.5%

4 3.9 13.5 27,895.5 15.4%

5ormore 9.0 31.0 94,408.6 52.2%

Total 29.0 100.0 180,959.0 100.0%

1997

NumberofConditions

Numberof


(millions)

Percentof


AmountofHealth

Spending

($millions)

PercentofTotal

HealthSpending

0 3.1 8.4 1,461.6 0.5%

1 4.1 11.1 11,691.0 4.4%

2 4.7 12.8 17,110.0 6.4%

3 5.3 14.6 27,074.0 10.1%

4 5.0 13.6 35,569.6 13.3%

5ormore 14.4 39.5 175,190.0 65.3%

Total 36.6 100.0 268,096.1 100.0%

2002

NumberofConditions

NumberofBeneficiariesAffected

(millions)

Percentof


AmountofHealthSpending

($millions)

PercentofTotal

HealthSpending

0 2.5 6.3 605.1 0.2%

1 3.0 7.5 9,414.7 2.6%

2 4.5 11.5 15,351.5 4.2%

3 4.6 11.8 26,776.0 7.4%

4 5.0 12.7 33,391.3 9.2%

5ormore 19.8 50.2 275,729.5 76.3%

Total 39.4 100.0 361,268.1 100.0%

2009

NumberofConditions

Numberof


(millions)

Percentof


AmountofHealth

Spending

($millions)

PercentofTotal

HealthSpending

0 2.8 6.4 1,798.3 0.4%

1 3.0 6.7 6,665.2 1.4%

2 4.2 9.5 20,843.2 4.5%

3 4.9 11.0 30,824.0 6.7%

4 5.8 13.2 43,819.5 9.5%

5ormore 23.6 53.3 359,050.0 77.5%

Total 44.3 100.1 463,000.2 100.0%


26/26



26

Source:Authorstabulationsbasedondatafromthe1987NationalMedicalExpenditureSurvey(NMES)andthe1997and2002MedicalExpenditurePanelSurvey(MEPS).

Note:Totalsmaynotaddto100becauseofrounding.

Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future

Documents

Transcript of Statement of Kenneth E. Thorpe, PhD - Hearing On Strengthening Medicare for Today and the Future